Older adult patients and family caregivers face numerous safety challenges when transitioning from the hospital to skilled home health (HH). This article describes how older adults and their family caregivers, HH frontline providers, HH leadership, and HH hospital-based transition coordinators, were engaged to identify best practices to implement the Hospital-to-Home Health Transition Quality (H3TQ) Index. This participatory co-design process identified ways patients, caregivers, and staff differ in how and when to administer the H3TQ Index, confirming the importance of engaging a wide range of stakeholders in design processes.

Well-designed workspaces minimize disruptions and distractions. This review and study describes several important ways to improve the anesthesia workspace in the operating room. Recommendations include demarcating an anesthesia zone with adequate space for equipment and storage and that restricts unnecessary staff travel into and through the zone. Each recommendation includes an illustrative diagram, explains its importance, and offers methods to achieve it.

Persons with dementia are at increased risk for adverse events compared to those without dementia, highlighting the importance of a timely diagnosis. In this study, researchers estimate approximately 20% of primary care patients aged 65 and older are expected to have a diagnosis of mild cognitive impairment or dementia; however, only 8% have received such a diagnosis. Missed diagnosis prevents patients from receiving appropriate care, including newly FDA-approved medications to slow cognitive decline.

Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.

Structured handoff tools can improve situational awareness and patient safety. This study describes the development and implementation of a bespoke tool for handoffs from the operating room to the neonatal intensive care unit (NICU). While use remained inconsistent during the study period, the goal of 80% compliance was achieved and 83% surveyed staff agreed or strongly agreed that the handoff provided needed information, up from 21% before implementation.

Surgical fires are a rare yet potentially harmful event for both patients and care teams. The alert provides reduction guidance for organizations to mitigate conditions that enable surgical fires and suggests tactics to improve communication as a primary strategy for preventing this potentially catastrophic accident in operating rooms.

Achieving high reliability remains difficult for many organizations. This article provides a brief history of the concept of high reliability organizations (HROs) and key features of high reliability culture, such as fostering trust and respect among teams and creating systems and processes to elicit feedback/reflections and identify opportunities for improvement. The authors discuss these concepts in the setting of anesthesiology and perioperative care.

Understanding factors that contribute to adverse events (AE) is key to preventing them from recurring. This study used an electronic trigger tool to identify potential AE in two dental practices. Of 439 charts reviewed, 13% contained at least one AE. The most common AE was post-procedural pain; the expert panel reported 21% of those AEs were preventable. Person-related factors (e.g., supervision, fatigue) were the most common contributing factors.

Laboratory tests are an integral part of diagnosing illness and injury, but system issues can result in the delayed communication of results to patients. This article describes use of the AHRQ toolkit Improving Your Office Testing Process to implement new testing and communication procedures. As an academic family practice clinic, an important first step was allowing residents to order tests and receive results in their own name instead of through an attending physician, which can cause delays in communication to patients. Providers and patients were satisfied with the new process.

Situational awareness is an essential component of teamwork. This qualitative study examined how situational awareness and team culture impact intraoperative handoff practice. Researchers found that participants often assumed that team members are interchangeable and that trained staff should be able to determine handoff appropriateness without having to consult the larger operating room team – both of these assumptions hinder team communication and situational awareness.

Cataract surgery is a common ophthalmic procedure in the United States and is increasingly performed in office-based settings. This study assessed the rates of intra- or post-operative adverse events in three types of lens surgeries, including cataracts. Findings suggest similar or lower adverse event rates for office-based cataract or refractive lens surgery when compared to surgeries performed in ambulatory surgery centers or hospital operating rooms.

Miscommunication between hospitals and community pharmacists at patient discharge can result in incorrect or incomplete medication distribution to patients. This study describes utilization and impact of the Transfers of Care Around Medicines (TCAM) service post-hospital discharge at community pharmacies. An increasing percentage of TCAM referrals were completed post-intervention, but 45% were not completed at all or took longer than one month. The impact of the TCAM service on adverse drug events (ADE) and unintentional medication discrepancies (UMD) was uncertain. Future research may explore reasons for low/late completions or focus on high-risk medications, as those were associated with the most ADE and UMD.

Diagnostic testing errors can contribute to delays in diagnosis and to serious patient harm. Researchers analyzed 327 voluntary incident reports from one medical center in the Netherlands and found that diagnostic testing errors most commonly occurred during the pre-analytic phase (77%), and were predominantly caused by human factors (59%). The researchers found that these diagnostic testing errors contributed to a potential diagnostic error in 60% of cases.

Cognitive aids such as mnemonics can help improve process reliability and promote patient safety. Based on an initial scoping review, this article describes a proposed taxonomy for clinical handoff mnemonics and their clinical processes and functions, which could help clinical teams design handoff mnemonics that best fit their workplace.

Implementation challenges can hinder the effectiveness of the WHO Surgical Safety Checklist (SSC). This study describes the validation of the Checklist Performance Observation for Improvement (CheckPOINT) tool to assess SSC implementation fidelity. Based on testing in simulated and real-life clinical practice, researchers found that that the tool can reliably assess implementation fidelity and identify opportunities for improvement.

The Accreditation Council for Graduate Medical Education (ACGME) requires post-graduate education to include patient safety curriculum. This article describes the development and evaluation of a curriculum for residents on patient safety investigations using the Root Cause Analysis and Action (RCA2) model. Residents were surveyed at least one year after completion of the training. Sixty-three percent of respondents agreed or strongly agreed residents should be provided with the RCA2 training and nearly half reported having participated on an RCA team since completing the program.